Transcript:

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CAVANAUGH: Facientes are usually released from the hospital with a handful of papers explain how they should take care of themselves when they get home. But when those patients are elderly and suffering from complex medical conditions, they often have difficulty managing their conditions at home and wind up being readmitted to the hospital. In fact, the government says 1-5 Medicare patients is readmitted within a month of release. In an effort to save money and help patient, many hospitals are turning to community-based support programs. In San Diego, that's the care transitions program just selected by Medicare to expand its services to thousands of patients across the county. My guest, doctor Nick Yphantides, and I'm going to address you as doctor Nick if that's okay with you.

YPHANTIDES: Absolutely.

CAVANAUGH: Welcome to the program.

YPHANTIDES: Thank you.

CAVANAUGH: Emily Awkerman is assistant director of case management at sharp healthcare. Welcome to the show.

AWKERMAN: Thank you, it's a pleasure to be here.

CAVANAUGH: And Don Ryan is with us, a patient who went through the transitions program at sharp memorial. Don, thank you for coming in.

RYAN: My pleasure.

CAVANAUGH: Let me start with you, doctor Nick. What are the reasons that so many Medicare patients are readmitted to the hospital?

YPHANTIDES: There are many of them. And many of them may not have anything to do with the hospital but have a lot to do with what experiences the patient has once they get discharged when they're back in their home environment. A lot of it has to do with confusion, mate of it may have to do with lack of communication, lack of awareness, challenge with getting follow-up appointments back to the doctor's office. So it's a multitude of considerations. What we're trying to do with this opportunity is bridge the gap between the hospital and what happens at home.

CAVANAUGH: Are there some illnesses that cause more readmissions than others?

YPHANTIDES: There are. And those illnesses would include things like heart failure, pulmonary disease, emphysema, other cardiovascular complications. Some medications and some illnesses are much more dependent on how things are coordinated in terms of how well patients do in the long run.

CAVANAUGH: Emily, would you say that some of these readmissions are preventible?

AWKERMAN: We absolutely believe that they're preventible. And that's why we're really excited to get going with this program so that when we know that the patients don't have to come in, given the proper resources, that we can keep them in their home where they're most comfortable and where they want to be.

CAVANAUGH: Now, the transitions program, doctor Nick, started in I believe 2009 as a pilot at sharp. What kind of services does it provide?

YPHANTIDES: Well, there are services basically what we call transition mentors and coaches that facilitate and identify patients who are at risk prior to discharge, follow them through the discharge to their home, do a home visit, and then help connect them to the various services that they need in the community.

CAVANAUGH: What kind of outcomes did this pilot transitions program produce that apparently it really impressed the government people, the Medicare people because they want to expand it now. So what kind of a result did you get in

YPHANTIDES: Well, there's different ways to look at the results. For example, you can look at the readmission rates at 30 days. And the baseline readmission rate at the hospital that we were working with at sharp was about 12%. The readmission rate for those who were in the pilot was less than 3%. So when you look at that, you can say, wow! By supporting these patients with these transition programs, it really made a big difference.

CAVANAUGH: So how this program now being expanded?

YPHANTIDES: Well, this program is being expanded county wide, and it's one of the things that we're very excited about. Sharp, Scripps, UCSD, and pal morhealth, and all 13 of their hospitals, we are now expanding this program with the goal of serving nearly 22,000 high-risk patients. So it's something that started at one location as a pilot that was proven to be effective and is now being expanded countywide. And it's a wonderful opportunity.

CAVANAUGH: It went from a pilot with 88 people, and Don, you were one of those 88 people! How did you hear about it?

RYAN: Within the hospital. I think I was one of the first ones they contacted. And I was -- had been in the hospital, it was a 10-day stay, and about maybe the 8th day they came in and said we're starting this program. Do you want to sign up? And I said sure, I'll volunteer for anything. [ LAUGHTER ]

CAVANAUGH: You're a veteran!

RYAN: Yeah, many times over.

CAVANAUGH: Okay. And why were you in the hospital?

RYAN: It was a multitude of things that caught up with an 83-year-old man. I had a case of bronchitis, my immune system was low, and I ended up with other infections. I had an ear infection, an eye infection, and I had a stomach problem. And that was the worst one. And it put me down for 10 days. And I was left weak. After I got out of there, I felt okay in my mind, but my -- like doctor Nick said, when you get out of there, there are things that you think you can do, you can't.

CAVANAUGH: Right.

RYAN: So it really helped having the people follow up and come back.

CAVANAUGH: How did they follow up?

RYAN: Well, Sharp had their team of transition people, and it was probably -- maybe I shouldn't be saying it, but at the time I'm supposed to be home-bound where I couldn't get around. But I was able to get around. And as soon as the nurse and a physical therapy came by, and they helped me out for the first couple weeks, simultaneously was the medical care nurse, Melissa, and she came by to introduce me to the program and doing the follow-up with my medicine. So I was getting a double whammy, so to speak.

CAVANAUGH: When she's coaches had their follow-up calls to you, did they explain things about the medication you were supposed to take and the way that you were supposed to maintain your health or your program in a way that became clearer to you?

RYAN: Oh, yes! It was an ongoing thing. I've had a lot of problems long before being in the hospital, so I did have a lot of medicines.

CAVANAUGH: Right.

RYAN: But there was adjustments to it after I got out of the hospital. I had a lot of problems of medications that are -- were giving me side effects, and that was affecting my coming and going. And they were there to see how I was responding to it. So they helped -- particular me Melissa, she was really good with making sure that what I had, how did I manage my taking my meds, I had about 15 different ones to take.

CAVANAUGH: That needs to be managed! [ LAUGHTER ]

RYAN: Big-time, yeah.

CAVANAUGH: And I hear that the people who came to your house actually helped you lose some weight.

RYAN: Oh, yeah, that came later. I didn't start losing weight -- my daughter and I were going to Weight Watchers, but I wasn't progressing. And last year, I had a big Afib attack, and the outcome with my cardiologist, he said you got to lose weight. And he gave me the stare of a doctor like you're not doing what you need to do. And he steered me out to the Sharp's weight management program. And I started that in July, 2012. And since then, I've lost 40 pounds. And it turned my life around. It was really a help.

CAVANAUGH: Thank you for telling us that story. As a case manager, Emily, I would imagine it's great hearing Don talk about how this program helped him. Did it sound to you as if someone in his particular situation might have been subject to readmission if it were not to for this program?

AWKERMAN: Absolutely. And that's exactly why he's one of the patients that we offered the program to. We have a lot of literature and studies that have been done out there in the country over the course of the last few years that help us to pinpoint the patients that are at high-risk. And I think Don was a classic example of that. Of a lot of different health conditions, multiple medications, his age, his weight, all those things sort of go together to paint the picture to us of someone who's high-risk that we think we can provide these coaching services and really make a difference for the patient.

CAVANAUGH: Now, doctor Nick, I understand that there are actually a number of different goals that go along with expanding the care transitions program. One is to reduce readmissions. By how much?

YPHANTIDES: The goal that we have committed to accomplishing is by 20%. And I will say and admit that this is potentially a little bit controversial because there are many who would say that not all, of course, readmissions are avoidable. We have to make sure that we focus on avoidable readmissions and we have the goal of routing those by 20%.

CAVANAUGH: That goes along with one of the other goals of this program, and that is to improve the quality of care. How will you go about assessing whether it's hitting that criteria?

YPHANTIDES: I like to tell people in God I trust, the rest of us need to show data! And we have all kinds of data is that we're going to be measuring. Ultimately what this is about is stewardship. We do not have the luxury with the escalating healthcare costs of just spending money. We have to reform the way we provide care. We have to make investments like this but do that in a way that shows outcomes, that shows quality and ultimately cost savings as well.

CAVANAUGH: There you go with the cost savings. Of the big goal is to save Sharp and other hospitals from being penalized for too many readmissions. These are new standards?

AWKERMAN: Yes. Last year, Medicare implemented some payment penalties related to readmission rates. All hospitals are measured, their readmission rates are compared to others. It is risk adjusted, and Medicare then says Sharp, you are above or below the standard for your type hospital, and therefore we're going to hold back part of the payment to you. So not long ago, there was a lot of public information that came out about that. And the situation with the hospitals here in San Diego. So because some of our hospitals did have slightly higher readmission rates, we are having some of our payments held back right now from Medicare.

CAVANAUGH: So it's important to the hospitals themselves and their bottom lines that this program work.

AWKERMAN: Absolutely. And not just from the payment penalty perspective because linking back to the quality comments, there are other quality metrics that Medicare publishes on us that also have an impact on our payment beyond the readmission rates.

CAVANAUGH: Let me go back to that question about the readmission, some people being concerned about the fact that since hospitals will be on the hook financially, are so to speak, if they exceed their readmissions, and that readmissions is a big piece of the president's Affordable Care Act, in order to reduce Medicare spending, that's why they're doing it, do you think that there is a possibility, doctor Nick, that hospitals are under too much pressure to reduce readmissions?

YPHANTIDES: Well, again, I think dependock who you talk to, you'll get different opinions on that. What I think is important about this opportunity is the community-based approach, to looking at this not as a problem of the institution itself but bridging the gap between the services that patients receive when they're sick enough to be in the hospital and connecting them to home-based and community-based services that they need once they get discharged. There's sort of a no-man's land right now between the hospital and the home or between the hospital and the skilled nursing facility that this program is looking to fill in the gaps. So it's not a blame, it's an important for us to collectively -- and we're very excited as part of our live well San Diego initiative to be part of this effort, because it's really without diluting the unique distinctions of each of the hospitals, it's looking at the situation from a community wideperspective.

CAVANAUGH: Let me ask you, Don, some people might hear about this program and think they will have a problem getting readmitted to a hospital if they really need to be in the hospital, if they're a Medicare patient. Did you ever feel that way?

RYAN: To a certain extent, I have a problem with my heart slowing down, and because I'm losing weight and my medications are becoming more powerful, so it affects how my heart rate goes. And I had to go in when it dropped down to about in the 30s and called the nurse and they said go to the hospital. Then the cardiologist said that's your new norm. So I said when should I start worrying? Because I didn't want to be coming back, and he says you're a worrier. So I have to assess myself, do I need to really call and go in there? And one of the things is, they're going to always say, yeah, call 911 and go in if you're having some thing with your heart, don't play games. But I've been in and out of the hospital so many times, I just want don't want to go back in.

CAVANAUGH: So you're the one who doesn't want to go back in! [ LAUGHTER ]

CAVANAUGH: So it's not so much a question of people being discouraged from readmissions, doctor Nick, if they really need them.

YPHANTIDES: Not at all. And yeah, I definitely think what we're looking at here is making sure that patients receive what they need when they need it in the right place and at the right time. And so by no mean, and that's the whole thing, some readmissions are not avoidable. But many are, and the focus here is to try to keep people like don in the most comfortable, preferable environment, and to do everything that we can to support that. It's in everybody's interests.